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I <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />14UN-KFFUNDAULL PERMIT <br />I:ALL ZUt1 VO3-/1121/ FOR INSPEGTIUNS tA.YIKt.7 T TLAR FROM UAIL I55ULU <br />Received <br />B <br />Check#/ <br />a <br />JOB ADDRESS Lathrop. Roo el <br />CITYizip Manteca, California <br />CROSS STREET North Union Road <br />APN I I r Q .0 (J 77 If r PARCEL SIZE 2 5 �1AND USE APPLICATION # <br />OWNER NAME The Schussing Company <br />1. W .) ); Q j.yl r PHONE (209) 380-0266 <br />OWNER ADDRESS 3000 Scenic Drive <br />CITY/STATE/ZIP Modesto, California 95355 <br />CONTRACTOR Krazan & Associates, Inc. <br />PHONE 559.348.2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />CITY/STATE/ZIP Clovis, CA 93612 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br />LICENSE J C-57 C-61 D-09 Other NUMBER 499908 EXPIRATION DATE 10/31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />JTENDED USE DomesticfPnvate Irrigation/Agricultural Industrial Water Quality Monitoring ol Sampling/Characterization <br />Public Water System <br />If different from Owner: Water system Name nn aName or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells _ Soil Boring(s) 0 of borings Geotechnical 10 N of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair ( /-0— S - f �) <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 10-50 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 4% in Thickness/Gauge/ASTM Sched Steel . Plastic Stainless Steel Other <br />Grout Seal Depth ft /Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method v+umped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal ' Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 U�E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED /1 TITLE Managing Engineer DATE 10/5/2017 <br />r� <br />D <br />a <br />A <br />N <br />X01 � <br />\�C;0' � <br />O� <br />DEPARTMENT USE ONLY <br />Application Accepted By Date I (� -Cl / Area A i'0N Employee ID# A))/,w/ m1 <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date _ WAIVER Received <br />Soil Boring Inspection By DateII U�Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />a <br />Amount <br />Remitted <br />Date Permit/ Invoice# WeIIID# <br />i Re uest <br />37), <br />I5 <br />330 IS <br />y3 <br />V' <br />EMD 4306 WELL /PUMP PERMIT <br />4130112 <br />